Getting Critical COVID-19 Protective Equipment in the Bay Area Has Been a Mess. Here's Why

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A health care worker at Alameda Hospital wears a protective mask with a message during a protest outside of the hospital on April 7, 2020. in Alameda, California. Dozens demanded better working conditions and proper personal protective equipment (PPE) amid the ongoing COVID-19 pandemic. (Justin Sullivan/Getty Images)

The classic N95 mask is a thin layer of fiber and filter, light enough to slightly flutter when you toss it in the air. For months, health care workers have thought of the masks as a key line of defense against a fast-spreading and insidiously sneaky virus — their perpetual enemy on the job.

As the coronavirus spread early on, more than half of California hospitals had just two weeks of critical N95 masks, though they were already experiencing hiccups in the supply chain, public records show. Now, as the Bay Area reopens, some hospitals and other health care facilities in the region are still fighting to keep enough personal protective equipment, or PPE, at the ready to shield workers against COVID-19.

There’s no coordinated federal leadership on stabilizing the global supply chain, and state contracts for protective gear have been slow to deliver.

That’s bad news for those who say their jobs are already being transformed, perhaps permanently, by the coronavirus. According to the California Department of Public Health, 13,476 workers have tested positive to date.

“I’m not afraid to go to work,” said Diane Fagen, who has been an emergency room nurse in Alameda County for 16 years. “My fear is, will I be able to keep up? And will the system that I work for become broke financially and otherwise? Because this burden is something that no system is prepared for.”

‘Frailties’ of the System

Health officers around the bay have said that a 30-day supply of PPE at health care facilities is a key threshold for loosening stay-at-home orders. As counties have steadfastly lifted their restrictions, some are still stabilizing the supply chain for protective gear, acting as a safety net both for hospitals that serve poor patients and for more resilient and wealthier hospital chains.

“To have COVID-19 come along and just lay bare all of the inadequacies of the unfairnesses of the resources that are available to the place that I work for ... is really, really frustrating,” said Fagen, an employee of Highland Hospital, part of the Alameda Health System.

The current crisis has revealed not only these persistent inequities among health care facilities, but the extent to which every hospital relies on some public support. It’s also a bad sign for any predicted surges in hospitalizations for COVID-19 cases, not to mention future pandemics.

“With any of these disasters, just for a moment, you get kind of a light flash on the frailties of the system,” said Alonzo Plough, vice president and chief science officer for the Robert Wood Johnson Foundation.

Hospitals Sound the Alarm

In January and again in March, hospitals and other health care facilities laid it on the line to the California Department of Public Health: There just weren’t enough N95s and other personal protective gear on hand, and the supply chain was shaky to boot.

That “chain” is more like a global web of links among manufacturers, middlemen, and medical offices that has been torn by sudden, competing demands from all over the world. Even six months ago, before the coronavirus crisis, local hospitals were already starting to feel it.

During the pandemic, nurses at Oakland’s Highland Hospital say they have been taught to store N95s that are used, but still functional in paper bags with their names on them, so they can last longer.

A spokesman for the Alameda Health System says he is unaware of such a policy, and that there is sufficient PPE on hand generally.

Laura Whitten, an emergency room nurse at Highland, said sanitizing wipes are scarce, so she uses improvised antibacterial cleaners, some made from bourbon or gin, to clean fingertip pulse meters between uses. “They remind me of hangovers,” she said. She also makes do with one wipe for an entire shift, saving it in a resealable baggie.

Tosan Boyo, San Francisco General’s chief operating officer and the city's lead for COVID-19 operations, says PPE shortages were acute during the pandemic’s early days.

"Things like gloves, face-shields, gowns, sanitizer wipes became extraordinarily scarce across the country. I could never depend on an order arriving. I didn't believe an order was real until it actually showed up at the loading dock,” Boyo said. “This is not an exaggeration."

KQED obtained two state surveys of health care facilities and hospitals, one in January and the other in March, through public record requests. Overwhelmingly, hospitals reported supply chain problems and the need for support and equipment from public agencies. About half said they had on hand just one or two weeks of N95 masks, the protective workplace standard against a transmissible disease like COVID-19.

“Supplies are ordered just in time,” Stanford Hospital reported to the California Department of Public Health in January. “We’re concerned that our suppliers will not be able to fulfill our orders given increased demands and that medical supplies are not being exported from China.” The same went for Lucille Packard Children's Hospital and Stanford-operated ValleyCare in Alameda County, Stanford Hospital said.

Community health centers sounded concerned, too. “We do not have an adequate supply of N95 masks,” wrote Open Door Community Health Centers, which operates a dozen clinics across Humboldt and Del Norte counties. Hundreds of miles to the south, the Community Hospital of the Monterey Peninsula told the state: “We would have enough PPE to supply a few patients at this time ... we have an emergency supply, but not confident that will last for 30 days[.]”

One reason hospitals were in a precarious situation is that maintaining a cache of supplies takes money, storage space and staff time. Low-inventory management — keeping a short supply on hand — is an increasingly common strategy in health care facilities, permitting a leaner and more decentralized operation.

There is no federal policy aimed at compensating for the fraying supply chain. The H1N1-virus crisis in 2009 depleted the Strategic National Stockpile, which warehouses everything from masks to ventilators to nerve agent antidotes in case of national emergency; its inventory of masks was never replenished. During the current pandemic, the Trump administration handed much of the responsibility for locating supplies to the Federal Emergency Management Agency. But according to Plough, a former emergency manager for the Los Angeles County Department of Public Health, while FEMA responds to crises, it does not typically manage and procure supplies.

“This is just not the usual way that the supply chain has been managed,” said Plough. “This is a huge departure. It's going to be hard for them to predict supply for PPE because of this.”

By March, about half of California hospitals reported they were short on masks, shields, gowns and gloves. Alameda County hospitals were worse off than the state, especially when it came to N95s. As cases began to rise, 10 out of 13 hospitals reported they had at most a couple of weeks’ worth.

Because of procurement problems, most hospitals reported having to reuse PPE, including expired equipment, while they requested more supplies from local agencies. Both Alta Bates campuses, Kaiser hospitals in Oakland and Richmond, St. Rose Hospital, Fairmont Hospital, Alameda Hospital, San Leandro Hospital and Highland Hospital were all in this category.

In May, KQED asked Alameda County hospitals how many weeks of N95s they had on hand.

Hospitals in the Alameda Health System, said spokesman Terry Lightfoot, have a two-week supply of their usual N95s available. AHS updates its characterization of the supply chain once a week, in a document now published on its website that codes supplies green, yellow or red, depending on availability.

But nurses, who are are in contentious negotiations with AHS over a new contract, point out that colors aren’t numbers: green, yellow and red don’t say enough about what's on hand.

“None of us are getting a good picture of how much PPE we’re going through,” said Whitten, a nurse at Highland Hospital. “We have all of the other numbers. Why can’t we get this one?”

Kaiser and Sutter hospitals declined to specify how many N95s they had on hand.

The state and some counties have said having enough protective gear to account for a surge in coronavirus cases is one of the indicators for loosening health orders. In Alameda County, health officials now have asked hospitals to certify their PPE levels. While the county wouldn’t disclose those certifications, officials have assessed PPE supply readiness countywide as a three on a five-level scale.


Got PPE? Richer versus Poorer Hospitals

Consolidated medical groups running multiple hospitals are more resilient to challenges obtaining N95s and other protective gear; money helps explain why.

Without confirming how much PPE it has available, Kaiser called supplies for its hospitals in Fremont, Oakland and San Leandro, “adequate.”

Sutter Health said it’s working to “closely manage” the supply of protective gear for Alta Bates in Berkeley and Alta Bates’ Summit campus in Oakland, including leveraging its multiple locations to shift supplies where they’re most needed.

“Our hospitals are not on their own. They have an entire network backing them up and working to help ensure they have what they need to care for patients now, while continuing to prepare for future surges,” said Monique Binkley Smith, communications manager for Sutter Health. “While we are encouraged by our progress in securing PPE, and our supply is currently adequate to match the current need, our job is far from over.”

But safety-net hospitals keep less cash on hand, because the federal government reimburses them for uninsured patients.

“They're a totally different financial structure and resource structure than the big academic medical centers,” said Plough.

Alameda Health System operates five hospitals; it was spun off from the county more than 20 years ago with the hopes of making its essential health care network more stable. It hasn’t worked that way. Now the system owes the county tens of millions of dollars, and it has had to ask county supervisors for money to keep going.

“I worry that the people who are in charge of this haven't been stellar in performance prior to this, and so it’s hard to have that leap of faith that everything is going to be OK,” said Fagen, the Highland Hospital nurse.

That history is part of why she’s skeptical of current reuse and pandemic protocols, and of using masks that have been resterilized, something that has been discussed but not implemented where she works.

“I feel like that’s going to bite us in the butt later.”

State Tries to Help

In the months since CDPH checked in with hospitals about their needs, California hasn't met Gov. Gavin Newsom’s lofty aspirations for a regular distribution of hundreds of millions of pieces of protective gear. At least not yet.

California’s own data shows that since the beginning of the pandemic, the state has distributed around 50 million N95 and 125 million surgical masks to counties. Earlier this month, Newsom announced the state was finally beginning to receive shipments of N95 masks from BYD, a Chinese manufacturer whose billion-dollar contract had to be extended when it couldn’t get its product federally certified as effective. Other, smaller mask contracts have fallen apart.

Even hospitals that report they’ve been able to keep protective gear flowing say federal and state support in an emergency is essential to the health care system, especially for small medical offices, which never used protective equipment this way before, and for nursing homes, whose needs have changed dramatically.

“The supply chain is not all equal. And our procurement and our ability to procure and further see into the supply chain is not all equal,” said Amanda Chawla, vice president of supply chain for Stanford University. “When you're dealing with a pandemic, you need the ability to support the nation and the community in a different way.”

State and federal stumbles have made the work of county emergency managers who have shored up supplies through local contracts and donations even more important.

The state reports it has distributed nearly 1.3 million N95 masks to Alameda County. By mid-May, the county had distributed about that many masks to health care facilities requesting them. On top of that, the county’s emergency managers have started to build a stockpile of their own.

Alameda County's N95 Guy

In a Dublin warehouse, a team led by Jim Morrissey has amassed a four-month supply of protective gear for Alameda County. That's enough, he said, to support all of the county’s health facilities at current levels of demand.

“I think we have more N95 masks here ... than the state of Massachusetts,” Morrissey said. “We’re in good shape.”

Morrissey is a linchpin with a mouthful of a title: He’s Alameda County Medical Health Operational Area Coordinator, or MHOAC. Every county has one, actually, as part of California’s emergency management system. But they don’t all operate like Morrissey.

Morrissey says he’s been able to fill just about every request from inside the county, distributing more than 15 million pieces of essential supplies in the fight against COVID-19 everything from masks to shields to gowns to thermometers to hand sanitizer. Word has traveled, he says, forcing him to turn down requests from elsewhere in the Bay Area and Northern California.

“I know other counties, actually, they want to see proof of a back order from a hospital before they will even attempt to fulfill a request,” Morrissey said. “We don't quite go that far. We just say we want you to try.”

What Is a 30-Day Supply, Anyway?

As with every other element of the pandemic response, each county has handled the challenges that health care facilities face in obtaining PPE differently.

Some localities have required hospitals and other facilities to certify they have access to 30 days of PPE as part of the set of “indicators” that guide reopening different types of businesses and activities.

But health care workers and their advocates point out that no common definition of a 30-day supply exists among counties, facilities or even workers, now that hospitals are using "preservation protocols” to economize PPE use during the pandemic, tactics like using isolation gowns in order to conserve more-protective surgical gowns, or disinfecting and reusing N95s.

Sal Rosselli, who heads the National Union of Healthcare Workers, claims that at Santa Rosa Memorial, access to N95s for nurses and other workers in surgery rooms is controlled. St. Joseph Health, which runs the hospital, disputes that. “We never deny a caregiver an N95 respirator in situations that are medically necessary, in fact, we encourage it; it's our policy,” the hospital said.

At Kindred Hospital, says Roselli, health care workers get one N95 a day.

“How do you define that they have a 30-day supply compared to, you know, a hospital that makes them readily available?” Rosselli said. “That 30-day supply definition is different from what we say is a must to be safe.”

Kindred did not respond to a request for comment.

However it’s defined, keeping more supplies at the ready is meant to protect against a surge in hospitalizations — a recurring fear in an often-uncontrolled pandemic.

Dr. Jennifer Tong, the associate chief medical officer at Santa Clara Valley Medical Center, said supply chain disruption might continue as long as there’s a state of emergency declared somewhere in the U.S.

“We expect that we might need to provide this support even if the local disaster has resolved,” she said.

Counties Pick Up the Tab

Shoring up supplies for health care facilities of all shapes and sizes is happening without an entirely clear picture of who will pay for it. At least some of the cost is being borne at the county level at a time when tax revenues, and consequently budgets, are shrinking.

The price of PPE is far from stable; Tong said the cost per unit has increased significantly for most items.

Morrissey of Alameda County says the county has spent at least $13.6 million on stockpiling protective equipment. According to Sgt. Ray Kelly, a public information officer in Alameda County’s Emergency Operation Center, the plan is to try to recoup 75% of expenses from FEMA for that work, as long as it lasts.

“We’re not going to stop buying PPE,” said Kelly. “Do we buy it for the next year, the next two years? Until we get a vaccine? We’re going to have to budget for PPE going into our county budgets for now on.”

Kelly points out that for Alameda and most counties, a new fiscal year begins in just a couple of weeks, and the pandemic has already changed spending priorities.

“We need to at least budget out for the next couple of years for PPE,” Kelly said. “At some point how much of the cost do you put on the taxpayer, where does our responsibility stop, and where do the corporations take over?

Pandemics have occurred before, Kelly says, but nothing like this. He compares COVID-19 to fires, now burning hotter and wilder around the state than they did before a century of mismanagement and changing climate.

Those fires caught many Northern Californians by surprise. Increasingly, counties and their residents are learning to prepare, attempting to minimize the consequences that follow, from a risk more frequent and deadlier than before.

Eventually, Kelly said, everyone’s got to buy their own flashlight.

Will Hospitals Plan Differently?

While Stanford University hospitals sounded concerned about protective equipment in earlier reports to the state, officials report relatively smooth operations for now.

Still, “I do think there will be a change in the industry,” said Stanford's Chawla. At the very least, Chawla suggests that some facilities might change their disaster planning protocols, and move from low-inventory strategies to warehousing supplies.

Emergency supplies from the Strategic National Stockpile kept Alameda Health System hospitals safe during the early peak of the pandemic; more than $60,000 worth of donated gear from a GoFundMe campaign helped supply the emergency room at Highland Hospital specifically.

But nurses and patient advocates say donations and stockpiles are no way to run a health care system.

Essential and safety-net hospitals around the country have been struggling for years, as federal and other reimbursements have dropped.

“It should be alarming, but it's a chronic alarming,” said Plough of the Robert Wood Johnson Foundation.

Nurse Whitten’s voice cracks as she talks about fatigue. In the ER, she says, they sometimes feel “alarm fatigue” — so many bells ringing at the same time, hour after hour, relentless.

She knows the public is feeling this way, too, because of quarantine and COVID-19 fears.

“As tired as you are, think of what it’s like for us,” she said.

Polly Stryker and Laura Klivans contributed additional reporting.

An earlier version of this article misidentified Monique Binkley-Smith's title.